Information and Aftercare Election

Please fill out the information below to confirm your appointment.

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Name

Physical Address

Phone

Mailing Address (If different)

Pet’s Name

Pet’s Species

Pet’s Breed

Pet’s Age (Approximate OK)

Pet’s Gender

Pet’s Color/Markings

Pet’s Weight

Trainer/Agent Name (If Applicable)

Regular/Referring Veterinarian

How did you hear about us?

Please check the boxes below to agree to the following statements. (required)

I, the undersigned, certify that I am the owner, or the duly authorized agent for the owner, of the animal described above. I am mentally competent, under no duress or the influence of drugs or alcohol, and I am over the age of eighteen.

I give High Tide Veterinary Services full and complete authority to euthanize said animal in a humane manner. I release Dr. Elizabeth Lee and High Tide Veterinary Services from any and all liability of said euthanasia. I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. I request, consent to, and order, euthanasia to be performed on said animal.

If the animal is insured, I understand that High Tide Veterinary Services is not responsible for notifying the insurance company. I confirm that the insurance company has been notified of the intended procedure if applicable.

I understand if cremation services are not elected, I am responsible for the disposal of my animal’s body. I understand that the body must be buried or disposed of safely according to local regulations within 12 hours to prevent harm to wildlife. I understand that my animal’s body cannot be used for consumption. I understand if cremation services are elected, that cremation is final and irreversible. Any items left with the pet will either be cremated with the pet or disposed of, on discretion of the crematorium.

I represent and warrant that the animal has not bitten any person or other animal during the past ten (10) days, and is not suffering from or been exposed to Rabies.

I assume all financial responsibility for all services rendered. I agree to pay for services in full at the time of service. If using credit/debit card I authorize High Tide Veterinary Services to charge the credit/debit card provided for services rendered at the time of service. I understand additional charges over the quoted amount may be incurred, for example if my pet is fractious or if the weight given above is not accurate. I agree to pay these charges if incurred.

Should I request, or it become necessary, to handle my own animal, I waive the option of legal action against High Tide Veterinary Services in the event I am injured. In the event damages occur to my property while High Tide Veterinary Services is in attendance, I waive legal and financial action against High Tide Veterinary Services.

By signing this form I am giving permission to end this animal’s life and I have the authority to execute this consent. I have read and understand this consent and voluntarily execute my authorization.

By typing my name and checking the above boxes, I agree that this electronic signature is the same as a handwritten signature for the purpose of validity and admissibility.

Full Name

Date

Aftercare Options

Cremation Options: (required)

No cremation elected. I will bury the pet on my property according to local regulations within 12 hours. I understand my pet’s body is not safe for consumption.

Communal: With the communal cremation service, each pet is carefully placed in the cremation chamber with other companions. No cremated remains are returned to the pet owner. Our trusted partners at Hearts Companion respectfully scatters the cremated remains on private property. The appropriate additional charge will apply.

Partitioned: Partitioned cremation is a cremation procedure in which multiple pets are cremated simultaneously while carefully separated in the cremation chamber. Partitioned cremations include cremated remains returned to you in your choice of urn. The appropriate additional charge will apply.

Private: A private pet cremation is the placement of a solitary pet within the crematory chamber. Your companion’s cremated remains are subsequently returned to you in your choice of urn. Full or partial viewings of the private cremation are an option for pet parents with this service. Please inquire for details. The appropriate additional charge will apply.

Communal Cremation Cost

Partitioned Cremation Cost

Private Cremation Cost

For partitioned or private cremation please choose one of the following options:

Standard Cedar Urn

Photo Cedar Urn

For partitioned or private cremation, optional engraving on the urn can be elected up to 4 lines, with up to 20 characters per line. Please write below exactly as you would like on the urn and select your desired font from the drop down menu below. Please note “, () etc will be engraved as written. Please leave blank if you would not like engraving or have chosen communal or no cremation. The following additional cost will apply: First two lines $25, Third line $10, Fourth line $10.

I do NOT want engraving

Font Options

Font Choice for engraving (if elected)

Clay Paw Print (required)

I would NOT like a clay paw print

I would like a clay paw print. I understand there will be an additional cost of $75. Please also select from the options below.

Name on claw paw print (if desired)

Ink Paw Print (required)

I would NOT like an ink paw print

I would like an ink paw print at no additional cost

Lock of fur (required)

I would NOT like a lock of fur

I would like a lock of fur at no additional cost

Remains and Keepsake Return (required)

I would NOT like any remains or keepsakes returned to me

I will pick up my items in 2-3 weeks from Soda Springs, CA. Details on location and instructions will be sent when the items are available.

I would like my items shipped to me when they are ready. I understand a $45 shipping charge will be applied. I understand High Tide Veterinary Services is not responsible for items lost or damaged by the shipping company or by Hearts Companion (our trusted cremation and keepsake company), or once the shipping company has delivered the items. I would like my items shipped to the following address:

USPS Shipping Address (if applicable)

If you would like to pay ahead of time, you may do so via Zelle, Venmo, Quickbooks bank transfer, or credit card. Please elect how you would like to pay below. Your total cost and more information on how to pay will be sent via e-mail. Please note any requests for refund of credit card payments will be charged a $50 fee to cover credit card processing fees.

Payment choice (required)

Thank you for filling out your information. Please let us know if you have any questions or concerns.